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Home My WebLink About- Septic Pumping Slip - 785 TURNPIKE STREET 1/22/2019 Commonwealth of Massachusetts City/Town of No. Andover SystemPumping � or Farm 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in i accordance with 310 CMR 16.351. A. i Facility information Important:When tilling out forms 1. System Location: on the computer, use only the tab TV key to moue your Address cursor-do not No.Andover use the return City/Town MA 01845 /Town key. tY State i Zip Code . 2. System Owner: Name reaan Address(if different from location) City/Tawn State Zip Code Telephone Number _ rd B. Pumping 1. Date of Pumping Date 2. Quantity Pumped:.. Gallons 3. Component: ❑ Cesspool(s) septic Tank ❑ Tight Tank © Grease Trap ® Other(describe): 4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: �a ca 6. S tem Pumped By: I Pi - ame" Vehicle License Number StewarVs Septic 58 So. Kimball St., Bradford MA Company 7. Location where contents were disposed: 20 So. Mill St. Bradford MA Sl�natu auler Date . I Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1